--- title: "Meaning & Key Takeaway of: When these accidents affect our…" description: "\"“When these accidents affect our customers, we seek to understand why it happened. The root cause is often deemed to be human error, and the all too co..." image: "https://sms4smile.com/quotes/i/5a0/gene-kim-2268_common-man_when-these-accidents-affect-our-customer_2672565.jpg" --- # When these accidents affect our customers, we seek to… ![“When these accidents affect our customers, we seek to understand why it happened. The root cause is often deemed to be human error, and the all too common management response is to “name, blame, and shame” the person who caused the problem.† And, either subtly or explicitly, management hints that…” quote by Gene Kim](https://sms4smile.com/quotes/i/5a0/gene-kim-2268_common-man_when-these-accidents-affect-our-customer_2672565.jpg) [Download](https://sms4smile.com/quotes/i/5a0/gene-kim-2268_common-man_when-these-accidents-affect-our-customer_2672565.jpg) [Open image](https://sms4smile.com/quotes/i/5a0/gene-kim-2268_common-man_when-these-accidents-affect-our-customer_2672565.jpg) > ““When these accidents affect our customers, we seek to understand why it happened. The root cause is often deemed to be human error, and the all too common management response is to “name, blame, and shame” the person who caused the problem.† And, either subtly or explicitly, management hints that the person guilty of committing the error will be punished. They then create more processes and approvals to prevent the error from happening again. Dr. Sidney Dekker, who codified some of the key elements of safety culture and coined the term just culture, wrote, “Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety-critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection.” These issues are especially problematic in the technology value stream—our work is almost always performed within a complex system, and how management chooses to react to failures and accidents leads to a culture of fear, which then makes it unlikely that problems and failure signals are ever reported. The result is that problems remain hidden until a catastrophe occurs.”” [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) ## About This Quote This interpretation was drafted with AI assistance. It is one reading of the quote, not the author's own explanation. Blaming individuals for errors creates fear, hindering safety and learning; a just culture encourages openness and systemic improvement. **In simple terms:** Blaming stops learning; a just culture promotes safety. Key Takeaway Adopt a just culture approach. Themes safety culture accountability systems thinking Mood cautionary instructive Type organizational ethical When to use this quote - manufacturing - software development - healthcare - aviation - risk management Key Concepts Just culture human error organizational learning Questions to Reflect On - How can organizations transition to a just culture? - What safeguards prevent misuse of “just culture”? A Different Perspective May be difficult to shift entrenched blame habits. ★ ★ ★ ★ ★ No ratings yet [Accidents Affect](https://sms4smile.com/quotes/about/accidents-affect-2515017/) [Accidents Leads](https://sms4smile.com/quotes/about/accidents-leads-2515016/) [Common man](https://sms4smile.com/quotes/about/common-man/) [Human error](https://sms4smile.com/quotes/about/human-error/) [Management](https://sms4smile.com/quotes/about/management/) [Response Blame](https://sms4smile.com/quotes/about/response-blame-2515018/) [Root cause](https://sms4smile.com/quotes/about/root-cause/) [Safety Culture](https://sms4smile.com/quotes/about/safety-culture-217589/) [Seek To Understand](https://sms4smile.com/quotes/about/seek-to-understand/) ## Related quotes > [When someone comes under abuse or attack a characteristic response is to blame yourself, especially if you are locked into a relationship of being…](https://sms4smile.com/quotes/mark-durie/when-someone-comes-under-abuse-or-attack-a-characteristic-response-is/) [Mark Durie](https://sms4smile.com/quotes/author/mark-durie/) > [Nuclear accidents anywhere can affect people everywhere.](https://sms4smile.com/quotes/ban-ki-moon/nuclear-accidents-anywhere-can-affect-people-everywhere/) [Ban Ki-moon](https://sms4smile.com/quotes/author/ban-ki-moon/) > [At the source of every error which is blamed on the computer, you will find at least two human errors, one of which is…](https://sms4smile.com/quotes/tom-gilb/at-the-source-of-every-error-which-is-blamed-on-the-computer-you-will/) [Tom Gilb](https://sms4smile.com/quotes/author/tom-gilb/) > [The alleviation of human error, whether design or intrinsically human, continues to be the most important problem facing aerospace safety.](https://sms4smile.com/quotes/jerome-f-lederer/the-alleviation-of-human-error-whether-design-or-intrinsically-human/) [Jerome F. Lederer](https://sms4smile.com/quotes/author/jerome-f-lederer/) > [Humans have 3 percent human error, and a lot of companies can't afford to be wrong 3 percent of the time anymore, so we…](https://sms4smile.com/quotes/walter-o-brien/humans-have-3-percent-human-error-and-a-lot-of-companies-can-t-afford/) [Walter O'Brien](https://sms4smile.com/quotes/author/walter-o-brien/) > [Probability of human error is considerably higher than that of machine error.](https://sms4smile.com/quotes/kenneth-appel/probability-of-human-error-is-considerably-higher-than-that-of/) [Kenneth Appel](https://sms4smile.com/quotes/author/kenneth-appel/) > [With both people and computers on the job, computer error can be more quickly tracked down and corrected by people and, conversely, human error…](https://sms4smile.com/quotes/isaac-asimov/with-both-people-and-computers-on-the-job-computer-error-can-be-more/) [Isaac Asimov](https://sms4smile.com/quotes/author/isaac-asimov/) > [A constant human error: to believe in an end to one's fantasies. Our daydreams are the measure of our unreachable truth. The secret of…](https://sms4smile.com/quotes/floriano-martins/a-constant-human-error-to-believe-in-an-end-to-one-s-fantasies-our/) [Floriano Martins](https://sms4smile.com/quotes/author/floriano-martins/) > [One of the most dangerous forms of human error is forgetting what one is trying to achieve.](https://sms4smile.com/quotes/paul-nitze/one-of-the-most-dangerous-forms-of-human-error-is-forgetting-what-one/) [Paul Nitze](https://sms4smile.com/quotes/author/paul-nitze/) > [“human error usually is a result of poor design: it should be called system error. Humans err continually; it is an intrinsic part of…](https://sms4smile.com/quotes/donald-a-norman/human-error-usually-is-a-result-of-poor-design-it-should-be-called/) [Donald A. Norman](https://sms4smile.com/quotes/author/donald-a-norman/) > [The history of human opinion is scarcely anything, more than the history of human errors](https://sms4smile.com/quotes/voltaire/the-history-of-human-opinion-is-scarcely-anything-more-than-the/) [Voltaire](https://sms4smile.com/quotes/author/voltaire/) > [We are not perfect, we have flaws, we have regrets and we make mistakes, these characteristics do not make us worthless, they make us…](https://sms4smile.com/quotes/rashida-rowe/we-are-not-perfect-we-have-flaws-we-have-regrets-and-we-make-mistakes/) [Rashida Rowe](https://sms4smile.com/quotes/author/rashida-rowe/) > [We must accept human error as inevitable - and design around that fact.](https://sms4smile.com/quotes/donald-berwick/we-must-accept-human-error-as-inevitable-and-design-around-that-fact/) [Donald Berwick](https://sms4smile.com/quotes/author/donald-berwick/) > [“The flawed human error is expecting someone else to build the world we desire, rather than creating it for ourselves.”](https://sms4smile.com/quotes/shawn-stern/the-flawed-human-error-is-expecting-someone-else-to-build-the-world/) [Shawn Stern](https://sms4smile.com/quotes/author/shawn-stern/) > [A guitar being played by an actual person is never going to be as precise and perfect as a programmed synthesizer. But we maintain…](https://sms4smile.com/quotes/matt-bellamy/a-guitar-being-played-by-an-actual-person-is-never-going-to-be-as/) [Matt Bellamy](https://sms4smile.com/quotes/author/matt-bellamy/) ## More by Gene Kim > [“for those organizations that provided a stock ticker symbol, we found that high performers had 50% higher market capitalization growth over three years. They…](https://sms4smile.com/quotes/gene-kim/for-those-organizations-that-provided-a-stock-ticker-symbol-we-found/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“A critical part of the Second Way is making wait times visible, so you know when your work spends days sitting in someone’s queue—or…](https://sms4smile.com/quotes/gene-kim/a-critical-part-of-the-second-way-is-making-wait-times-visible-so-you/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“when something does go wrong, we conduct blameless post-mortems, not to punish anyone, but to better understand what caused the accident and how to…](https://sms4smile.com/quotes/gene-kim/when-something-does-go-wrong-we-conduct-blameless-post-mortems-not-to/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“Bill Baker, a distinguished engineer at Microsoft, quipped that we used to treat servers like pets: “You name them and when they get sick,…](https://sms4smile.com/quotes/gene-kim/bill-baker-a-distinguished-engineer-at-microsoft-quipped-that-we-used/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“To even get feedback from our integration process would require twenty-four to thirty-six hours.”](https://sms4smile.com/quotes/gene-kim/to-even-get-feedback-from-our-integration-process-would-require/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“work can bounce between teams endlessly due to incomplete information, or work can be passed onto downstream work centers with problems that remain completely…](https://sms4smile.com/quotes/gene-kim/work-can-bounce-between-teams-endlessly-due-to-incomplete-information/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“practicing five minutes daily is better than practicing once a week for three hours. And if you want to create a genuine culture of…](https://sms4smile.com/quotes/gene-kim/practicing-five-minutes-daily-is-better-than-practicing-once-a-week/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“habits are what enable mastery.”](https://sms4smile.com/quotes/gene-kim/habits-are-what-enable-mastery/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“20% on detailed planning (Their poor throughput and high lead times were misattributed to faulty estimation, and so, hoping to get a better answer,…](https://sms4smile.com/quotes/gene-kim/20-on-detailed-planning-their-poor-throughput-and-high-lead-times/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“Features are always a gamble. If you’re lucky, ten percent will get the desired benefits.”](https://sms4smile.com/quotes/gene-kim/features-are-always-a-gamble-if-you-re-lucky-ten-percent-will-get-the/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“I listen to Wes and Patty brainstorm ideas to reduce yet another dependency on Brent when something starts to bother me. Erik called WIP,…](https://sms4smile.com/quotes/gene-kim/i-listen-to-wes-and-patty-brainstorm-ideas-to-reduce-yet-another/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [The status quo (of development) pre-ordains failure from the very beginning.](https://sms4smile.com/quotes/gene-kim/the-status-quo-of-development-pre-ordains-failure-from-the-very/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“high performers were twice as likely to exceed profitability, market share, and productivity goals. And,”](https://sms4smile.com/quotes/gene-kim/high-performers-were-twice-as-likely-to-exceed-profitability-market/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“we value improvement of our daily work more than daily work itself.”](https://sms4smile.com/quotes/gene-kim/we-value-improvement-of-our-daily-work-more-than-daily-work-itself/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) > [“Alert fatigue is the single biggest problem we have right now…We need to be more intelligent about our alerts or we’ll all go insane.”](https://sms4smile.com/quotes/gene-kim/alert-fatigue-is-the-single-biggest-problem-we-have-right-now-we-need/) [Gene Kim](https://sms4smile.com/quotes/author/gene-kim/) [Explore all 175 Gene Kim quotes ](https://sms4smile.com/quotes/author/gene-kim/) ## More Common man quotes > [Those who advocate common usage in philosophy sometimes speak in a manner that suggests the mystique of the 'common man.'](https://sms4smile.com/quotes/bertrand-russell/those-who-advocate-common-usage-in-philosophy-sometimes-speak-in-a/) [Bertrand Russell](https://sms4smile.com/quotes/author/bertrand-russell/) > [In a democracy, voting is a huge and most important right of a common man.](https://sms4smile.com/quotes/pankaj-tripathi/in-a-democracy-voting-is-a-huge-and-most-important-right-of-a-common/) [Pankaj Tripathi](https://sms4smile.com/quotes/author/pankaj-tripathi/) > [Through my singing and acting and speaking, I want to make freedom ring. Maybe I can touch people's hearts better than I can their…](https://sms4smile.com/quotes/paul-robeson/through-my-singing-and-acting-and-speaking-i-want-to-make-freedom/) [Paul Robeson](https://sms4smile.com/quotes/author/paul-robeson/) > [It's nice that people can call me an artist and it's nice that I can refer to myself as such, but it also kind…](https://sms4smile.com/quotes/matana-roberts/it-s-nice-that-people-can-call-me-an-artist-and-it-s-nice-that-i-can/) [Matana Roberts](https://sms4smile.com/quotes/author/matana-roberts/) > [The common man, finding himself in a world so excellent, technically and socially, believes it has been produced by nature, and never thinks of…](https://sms4smile.com/quotes/jose-ortega-y-gasset/the-common-man-finding-himself-in-a-world-so-excellent-technically/) [Jose Ortega y Gasset](https://sms4smile.com/quotes/author/jose-ortega-y-gasset/) > [No one got rich on a government program. Do not choose to be a common man. You can be uncommon.](https://sms4smile.com/quotes/dave-ramsey/no-one-got-rich-on-a-government-program-do-not-choose-to-be-a-common/) [Dave Ramsey](https://sms4smile.com/quotes/author/dave-ramsey/) > [Under capitalism the common man enjoys amenities which in ages gone by were unknown and therefore inaccessible even to the richest people. But, of…](https://sms4smile.com/quotes/ludwig-von-mises/under-capitalism-the-common-man-enjoys-amenities-which-in-ages-gone/) [Ludwig von Mises](https://sms4smile.com/quotes/author/ludwig-von-mises/) > [The founder of any branch must be more ingenious than the common man. However, if his achievement is not carried on by disciples of…](https://sms4smile.com/quotes/bruce-lee/the-founder-of-any-branch-must-be-more-ingenious-than-the-common-man/) [Bruce Lee](https://sms4smile.com/quotes/author/bruce-lee/) > [I am terrified of restrictive religious doctrine, having learned from history that when men who adhere to any form of it are in control,…](https://sms4smile.com/quotes/james-a-michener/i-am-terrified-of-restrictive-religious-doctrine-having-learned-from/) [James A. Michener](https://sms4smile.com/quotes/author/james-a-michener/) > [“Creative writer has artistic sensibility. He observes the world like any common men. But his vision observes the world quite differently. He can perceive…](https://sms4smile.com/quotes/aristotle/creative-writer-has-artistic-sensibility-he-observes-the-world-like/) [Aristotle](https://sms4smile.com/quotes/author/aristotle/) > [The commander of the forces of a large State may be carried off, but the will of even a common man cannot be taken…](https://sms4smile.com/quotes/confucius/the-commander-of-the-forces-of-a-large-state-may-be-carried-off-but/) [Confucius](https://sms4smile.com/quotes/author/confucius/) > [Common men should esteem learning as silver, noble men prize it as gold, and princes as jewels.](https://sms4smile.com/quotes/pope-pius-ii/common-men-should-esteem-learning-as-silver-noble-men-prize-it-as/) [Pope Pius II](https://sms4smile.com/quotes/author/pope-pius-ii/) > [Hathiram Choudhary is a vulnerable, intense and deep character. Like every common man, he just wants to prove himself and better himself. But he…](https://sms4smile.com/quotes/jaideep-ahlawat/hathiram-choudhary-is-a-vulnerable-intense-and-deep-character-like/) [Jaideep Ahlawat](https://sms4smile.com/quotes/author/jaideep-ahlawat/) > [Those who respect the intelligence of the common man have always been masters.](https://sms4smile.com/quotes/suhasini-maniratnam/those-who-respect-the-intelligence-of-the-common-man-have-always-been/) [Suhasini Maniratnam](https://sms4smile.com/quotes/author/suhasini-maniratnam/) > [I know that a lot of people take inspiration from the fact that I was just a common man with no film background who…](https://sms4smile.com/quotes/uday-kiran/i-know-that-a-lot-of-people-take-inspiration-from-the-fact-that-i-was/) [Uday Kiran](https://sms4smile.com/quotes/author/uday-kiran/) [Browse all 367 Common man quotes ](https://sms4smile.com/quotes/about/common-man/) ```json { "@context": "https://schema.org", "@graph": [ { "@type": "Quotation", "text": "“When these accidents affect our customers, we seek to understand why it happened. 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Dr. Sidney Dekker, who codified some of the key elements of safety culture and coined the term just culture, wrote, “Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety-critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection.” These issues are especially problematic in the technology value stream—our work is almost always performed within a complex system, and how management chooses to react to failures and accidents leads to a culture of fear, which then makes it unlikely that problems and failure signals are ever reported. 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